NCLEX-RN: Psychiatric Nursing

Psychiatric Nursing: Psychotropic Drugs

Focus topic: Psychiatric Nursing

Definition: Psychotropic drugs are those used in psychiatry in conjunction with other forms of therapy that affect psychic functioning, mood, behavior, or experience; and are used to treat symptoms of psychiatric disorders.

Characteristics
A. Psychotropic drugs affect both the central and autonomic nervous systems.
B. These drugs affect behavior indirectly by chemically interacting with other chemicals, enzymes, or enzyme substrates.

  •  Changes in cellular, tissue and organ functions occur.
  • Drug effects vary from cellular activity to effect on psychosocial interaction.

C. Most psychotropic medications affect biological imbalances in the brain.

Psychiatric Nursing: Anti-psychotic Drugs

Focus topic: Psychiatric Nursing

A. Drugs also known as neuroleptic; introduced about 1953.
B. Action: block the dopamine receptors in the CNS.
C. Anti-psychotic drugs relieve positive psychotic symptoms and assist in controlling behavior. Used in the treatment of schizophrenia and psychosis associated with other psychiatric and medical conditions.
D. Earliest are phenothiazine derivatives called conventional or “typical”: Thorazine (chlorpromazine), Stelazine (trifluoperazine), Trilafon (perphenazine), Prolixin (fluphenazine).

  •  Extra pyramidal side effects (EPSEs) occur most commonly when phenothiazines are utilized, affecting voluntary movements and skeletal muscles.
    a. Drug-induced parkinsonism (pseudoparkinsonism): symptoms occur in 1–4 weeks; signs are similar to classic parkinsonism  rigidity, shuffling gait, pill-rolling hand movement, tremors, dyskinesia, and mask like face.
    b. Akathisia: very common; occurs in 1–6 weeks. Signs: uncontrolled, uncomfortable motor restlessness, foot tapping, agitation, pacing.
    c. Dystonia: occurs as early as 1–2 days. Signs: limb and neck spasms (torticollis); muscle pain; difficulty in speaking and swallowing; and rigidity and spasms of muscles (oculogyric crisis is upward involuntary eye position).
    d. Tardive dyskinesia: usually develops late in treatment, may be reversed if diagnosed early and treatment causing the condition is stopped. May be irreversible. Antiparkinson drugs are of no help in decreasing symptoms; characterized by facial grimacing, tongue thrusting, repetitive chewing, shuffling gait, drooling, and general dystonic symptoms.
  •  Movement disorder scales can aid in assessment.

E. Another common anti-psychotic drug (classification  butyrophenones) is Haldol (haloperidol).

  •  Extreme caution in use with the elderly.
  •  Also used in treatment of Tourette’s syndrome.
  •  Incidence of severe extra pyramidal reactions.
  • Other side effects include leukocytosis, blurred vision, dry mouth, urinary retention, and cardiac changes. When administered intravenously, continuous cardiac monitoring is often required. Other possible and serious side effects: neuroleptic malignant syndrome, hyperpyrexia, and heat stroke.
  • Causes sedation; avoid alcohol and other CNS depressants.

F. “Atypical anti-psychotics,” such as Risperdal, Seroquel (quetiapine), Zyprexa (olanzapine), Geodon (ziprasidone), and Ability (aripiprazole). Invega Sustenna (paliperidone palmitate) is a newer atypical anti-psychotic.

  •  These drugs have fewer extra pyramidal symptoms
  •  Can cause major weight gain and metabolic changes.
  •  Cardiac side effects including hypotension can occur.
  •  Increase in liver enzymes, blood dyscrasias, and neuroleptic malignant syndrome are potential effects; frequency with individual drugs varies or may not occur.

G. Clozaril (clozapine): an atypical antipsychotic for management of psychotic symptoms in clients who do not respond to other antipsychotics.

  • Rare or low incidence of extra pyramidal effects and tardive dyskinesia.
  •  Side effects similar to other anti-psychotics; be aware of blood dyscrasias (leukopenia, neutropenia, agranulocytosis, eosinophilia).
  •  Requires weekly white blood cell (WBC) count to determine potential for agranulocytosis. (Drug is discontinued if WBC < 2000 μL or granulocytes < 1000 μL.)
  • Monitor monthly bilirubin, liver function studies.

H. Thioxanthenes: Taractan (chlorprothixene) and Navane (thiothixene).
I. Other antipsychotic side effects. Incidence and severity vary by drug.

  •  Blood dyscrasias.
    a. Agranulocytosis occurs in first 4–18 weeks of treatment. Symptoms: fever, sore throat, malaise, infection.
    b. Leukopenia, preceded by altered WBC count.
  •  Extra pyramidal symptoms and hormonal changes.
  • Hypotension: Orthostatic hypotension may occur. Monitor closely when client is elderly. Keep client supine for 1 hour and advise to change positions slowly. Fall risk, cardiac changes.
  •  Anticholinergic effects: dry mouth, blurred vision, tachycardia, nasal congestion, and constipation. Treat symptomatically.
  •  Neuroleptic malignant syndrome a rare complication caused by an anti-psychotic is a medical emergency (20% mortality rate) and must be recognized and treated immediately.
    a. Signs and symptoms: muscle rigidity/ motor abnormalities, hyperpyrexia, altered mental status, autonomic instability, irregular vital signs, elevated creatine phosphokinase, and possibly acute renal failure.
    b. Treatment: immediate discontinuation of drug, medical monitoring, administration of a dopamine-enhancing drug and/or Dantrium (dantrolene) and aggressive supportive medical treatment.
Psychiatric Nursing

 

 

Psychiatric Nursing: Anti-parkinson Drugs

Focus topic: Psychiatric Nursing

A. The term extra pyramidal disease refers to a motor disorder often associated with pathologic dysfunction in the basal ganglia. Antiparkinson drugs block the extra pyramidal symptoms.

  • Clinical symptoms of the disease include abnormal involuntary movement, change in tone of the skeletal muscles, and a reduction of automatic associated movements.
  •  Reversible and irreversible extra pyramidal reactions may follow the use of certain drugs—the most common are the phenothiazine derivatives.

B. Antiparkinson drugs act on the extra pyramidal system to reduce disturbing symptoms experienced from anti-psychotic medications.

  •  They are usually given in conjunction with anti-psychotic drugs.
  •  The most common drugs are anticholinergics: Artane (trihexyphenidyl), Cogentin (benztropine), Kemadrin (procyclidine), and Akineton (biperiden).
  • Side effects are dizziness, gastrointestinal disturbance, headaches, urinary hesitancy, restlessness, and memory impairment.

C. Benadryl (diphenhydramine), an antihistamine, is often given in place of Artane or Cogentin.

  •  Controls the extra pyramidal side effects of phenothiazines.
  •  Preferred because it does not cause as many untoward side effects as the other antiparkinson drugs.

D. Other drugs occasionally ordered in this category are Symmetrel (amantadine), benzodiazepines, (Inderal) propranolol, Catapres, Procardia (nifedipine), Verelan (verapamil), and Dantrium used for treating neuroleptic malignant syndrome.

Psychiatric Nursing: Anxiolytic (Anti-anxiety) Drugs

Focus topic: Psychiatric Nursing

A. Drugs induce sedation, relax muscles, and inhibit convulsions; major use to reduce anxiety.
B. These drugs are the most frequently prescribed drugs in medicine; demand is great for relief from anxiety and they are safer than sedative–hypnotics.
C. Potentiate drug abuse. Greatest harm occurs when combined with alcohol.
D. Prescribed for psychological distress, psychosomatic disorders, or functional psychiatric disorders, but do not modify psychotic behavior.
E. Classes of drugs

  •  Benzodiazepines: Librium (chlordiazepoxide), Valium (diazepam), Ativan (lorazepam), Klonopin (clonazepam), and Xanax (alprazolam) are used in depression, panic, and obsessive–compulsive disorders. Side effects: sedation, confusion, dizziness, paradoxical excitement.
  •  Nonbenzodiazepine: BuSpar (buspirone) does not depress CNS. Side effects: dizziness, headaches, nausea.
  •  Antihistamines are sometimes used to treat anxiety but are not as effective: Vistaril (hydroxyzine), Atarax (hydroxyzine), and Benadryl.
  •  Antidepressants: see Antidepressant Drugs for additional information.

F. Frequency and severity of side effects vary by drug.

  •  Drowsiness (avoid driving or working around equipment).
  •  Blurred vision, mental confusion, dermatitis, paradoxical excitement.
  •  Habituation and increased tolerance may develop.
  • Pancytopenia, thrombocytopenia, and granulocytopenia.
  •  Withdrawal symptoms occur with prolonged use (6+ months) and high doses.

Psychiatric Nursing: Antidepressant Drugs

Focus topic: Psychiatric Nursing

Definition: Drugs used for the treatment of major depressive disorders. Act by increasing concentration of neurotransmitters in the brain.
A. Tricyclic antidepressants include Elavil (amitriptyline), Norpramin (desipramine), Tofranil (imipramine), Aventyl and Pamelor (nortriptyline).

  •  Block uptake of norepinephrine and serotonin.
  •  A lag period of 1 to 6 weeks between starting the medication and experiencing symptom relief exists.
  •  Effective but generally replaced by newer antidepressants that cause fewer side effects.
  •  Side effects.
    a. Anticholinergic effects: dry mouth, blurred vision, constipation, postural hypotension, urinary retention.
    b. CNS effects: tremor, sedation, seizures.
    c. Cardiovascular and cardio  toxic effects; changes in the electrical conduction. Assess any client with history of cardiovascular disease, especially heart block.
    d. Elderly clients should have electrocardiogram (ECG).
    e. Alterations in sexual functioning
    f. Induce mania.
    g. Weight gain.
    h. Most side effects appear in first 1 to 2 weeks and diminish or are better tolerated over a period of a few weeks or months.
  •  If client is switched from a tricyclic drug to a monoamine oxidase (MAO) inhibitor, a period of 1 to 3 weeks must elapse between drugs.
  •  Blood level assays provide therapeutic levels of tricyclic antidepressants.

B. MAO inhibitors include Marplan (isocarboxazid), Nardil (phenelzine), and Parnate (tranylcypromine).

  •  MAO inhibitors are potent and have the potential to produce many serious side effects.
  •  Not the first antidepressant of choice because of side effect profile. Many dietary restrictions.
  •  Side effects.
    a. Most dangerous is hypertensive crisis.
    b. Drug interactions (sympathomimetic medications) can cause severe hypertension, hypotension, or CNS depression.
    c. Postural hypotension, headaches, constipation, anorexia, diarrhea, and chills.
    d. Tachycardia, edema, impotence, dizziness, insomnia, and restlessness.
    e. Manic episodes and anxiety.
  • All clients must be warned not to eat foods with high tyramine content (aged cheese, pickled fish, meat extracts, red wine, beer, chicken liver, yeast); certain vegetables (pea pods, fava beans); bananas; combination foods such as pizza, lasagna, quiche, liver pate; soy sauce; sauerkraut; drink alcohol; or take other drugs, especially sympathomimetic drugs (amphetamines, l-dopa, epinephrine).
  • MAO inhibitors must not be used in combination with tricyclics.

C. Hypertensive crisis, due to elevated tyramine levels.

  •  Severe symptoms: throbbing, occipital headache, confusion, drowsiness, vomiting, stiff neck, chills, chest pain.
  •  Monitor for potential complications: encephalopathy, heart failure.
  •  Treatment.
    a. Discontinue MAO inhibitor (MAOI).
    b. Administer short-acting anti-hypertensives.
    c. Monitor vital signs, ECG, and neurological signs; blood pressure (BP) q 5 min, cooling measures.

D. Selective serotonin re-uptake inhibitors (SSRIs).

  •  Drugs are highly selective for the serotonin pathway and exert little or no effect on the uptake of the other neurotransmitters or receptor sites.
  •  SSRIs include: Prozac (fluoxetine), Zoloft (sertraline), Paxil (paroxetine), Celexa (citalopram), and Lexapro (escitalopram).
  • Exhibit fewer side effects than other antidepressant drugs.
    a. Side effects: nausea (most common), anxiety/nervousness, insomnia, drowsiness, and headache.
    b. Co administration of alcohol and drugs is not recommended.
    c. Discontinuation syndrome is often seen with SSRI, but can occur with other psychotropic medication when the medication is stopped suddenly. Irritability, dizziness, insomnia, nightmares, ataxia, lethargy, headaches, and GI disturbance can occur. Gradually tapering medication over a few weeks minimizes development of symptoms.
    d. Serotonin syndrome is a potentially life threatening syndrome when the body’s level of serotonin is elevated. Signs and symptoms include agitation, diarrhea, fever, mental status changes, muscle spasms, hyperreflexia, tremor, ataxia, erratic blood pressure, metabolic acidosis, and tachycardia. Must be taking serotonergic drug to be diagnosed with serotonin syndrome. Treatment includes Periactin (cyproheptadine) to block serotonin production, benzodiazepines, and other supportive measures. Life threatening if untreated.
  •  Note danger of giving SSRIs to children.

E. Other antidepressants.

  •  Desyrel (trazodone hydrochloride) is a member of a class of antidepressant drugs unrelated to the tricyclics.
    a. Inhibits the reuptake of serotonin.
    b. Well tolerated, with minimal side effects (sedation and orthostatic hypotension).
    c. Warning: this drug has been associated with priapism—persistent, abnormal erection. If symptom occurs, immediately discontinue drug.
  •  Wellbutrin (bupropion): unrelated to other antidepressants.
    a. Used to treat depression and seasonal affective disorder as well as for smoking cessation.
    b. Side effects: headache, weight loss, insomnia, GI disturbance, tachycardia, dry mouth.
  • Serotonin norepinephrine reuptake inhibitors (SNRIs)
    a. Include Effexor (venlafaxine), Cymbalta (duloxetine).
    b. Block uptake of both norepinephrine and serotonin.

Psychiatric Nursing: Mood Stabilizers (Antimanic Drugs)

Focus topic: Psychiatric Nursing

A. These drugs control mood disorders, especially the manic phase.
B. Elevate mood when client is depressed; dampen mood when client is in manic episode.
C. Before lithium therapy is begun, baseline studies of renal, cardiac, and thyroid status obtained.
D. The most common form of drug is lithium carbonate, a naturally occurring metallic salt; other forms include lithium citrate.
E. Drug must reach a certain blood level before it is effective—0.6–1.2 mEq/L.

  •  Stabilizing concentration occurs in 5 to 7 days; therapeutic effect 7 to 28 days or more.
  •  Drug dose is maintained at 900–1200 mg/ day to achieve serum level maintained in range of 0.6–1.2 mEq/L. Often drug is gradually increased to achieve therapeutic range and to minimize side effects.

F. Lithium is metabolized by the kidney.

  •  Deficiency of sodium results in more lithium being reabsorbed (lithium substitutes for sodium ion), thus increasing risk of toxicity.
  •  Excessive sodium causes more lithium to be excreted and may lower level to a non-therapeutic range.
  •  Normal dietary intake of sodium with adequate fluids to prevent dehydration is necessary.
  • Diuretics will increase absorption of lithium leading to toxic effects.
  •  Serum levels measured two to three times weekly (12 hours after last dose) in beginning of therapy; for long-term maintenance therapy, every 2 to 3 months.

G. Drug concentration and side effects.

  •  Therapeutic range of serum levels is 0.6–1.2 mEq/L.
  • Side effects occur at upper ranges,
  •  Gastrointestinal disturbances, weight gain, hair loss, metallic taste in mouth, muscle weakness, fatigue, thirst, polyuria, and fine hand tremors are common side effects.
  • Hypothyroidism is a long-term side effect of lithium therapy.

H. For acute manic episodes, Zyprexa has been approved.
I. Risperdal combined with lithium provides more rapid mood stabilization than lithium alone.
J. For clients who cannot take lithium, seizure medications may be prescribed, including Tegretol (carbamazepine), Depakote, and Lamictal (lamotrigine). Serum blood levels are utilized to monitor Tegretol and Depakote. Lamictal can cause serious and life-threatening rashes requiring hospitalization. Topamax (topiramate) and Trileptal (oxcarbazepine) are other seizure medications prescribed for mood stability.

K. Lithium toxicity.

  •  Appears when blood level exceeds 1.5 to 2.0 mEq/L. May appear sooner depending on individual client.
  • Central nervous system is the chief target.
  • Signs and symptoms include nausea, vomiting, drowsiness, tremors, slurred speech, blurred vision, muscle twitching, oliguria, confusion, unsteady gait.
  •  If drug is continued, coma, convulsions, and death may result.
  •  Treatment for toxicity: gastric lavage, correction of fluid balance, administration of Osmitrol (mannitol) to increase urine excretion.

Psychiatric Nursing: General Nursing Responsibilities for Administering Psychoactive Drugs

Focus topic: Psychiatric Nursing

A. Give correct drug and dose at correct time to correct client. Use two client identifiers.
B. Know specific actions and uses of drugs.
C. Be familiar with the side effects and precautions of major drug groups.
D. Observe client carefully for side effects.
E. Be aware that certain drug groups are not compatible  know half-lives and drug interactions.
F. Notify doctor of extra pyramidal side effects and lithium toxicity, and immediately implement nursing intervention.

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